Travel Insurance Waiver Form

Travel Insurance Waiver Form

Please complete the form to acknowledge the terms and conditions of your booking, liability release, COVID-19 policies and travel insurance preference.
Name of Traveler:

First NameLast Name
Email Address to Receive Copy of Your Response to This Form
example@example.com
The information on my reservation, which includes but is not limited to my name, date of birth, trip dates, destination, accommodations, and departure/return airport are correct. I understand there are fees associated with making changes to the above once a payment is made.
I have read and understand the terms and conditions as it relates to my booking as provided to me by my travel agent and assume all risks associated with my travel itinerary.
I have read and understand the cancellation policies outlined in my itinerary, understand all fees associated with the cancellation of my travel services and have been made aware of the benefits of travel protection. At this time I have decided to:
By selecting "request additional time to consider the travel insurance quote presented...", you are acknowledging that you have read and understand the deadline for making a purchase. The traveler is responsible for notifying the agent of their intent to purchase insurance (and make the payment for the policy desired) or not by the due date.
Release of Liability:

Phenomenal Moments Travel offers retail travel services to clients, which are provided by separate and independent vendors of travel services. Phenomenal Moments Travel does not operate, control, or otherwise provide the services of independent travel vendors. Hence, by submitting this form, the client agrees that Phenomenal Moments Travel acts only as an agent for the client in acquiring transportation, hotel accommodations, sightseeing, and other privileges, or services for the client’s benefit, and on the express condition that Phenomenal Moments Travel shall not be responsible for any loss, accident, injury, delay, defect, omission or irregularity which may occur or be occasioned, whether by reason of any act, negligence or default of any company or person engaged in or responsible for carrying out any of the arrangements, or otherwise in connection therewith.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: